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Customer Registration Form
Let's start with your Full Name:
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What email address can we reach you at?
*
Where do you live?
*
What is your Phone Number?
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What is your Date of Birth?
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Are you married?
Yes
No
How long have you been married?
Do you have kids? If so how old are they and what do they do?
What is your Educational Qualification?
I am
a Business Owner
a Salaried Employee
Others
Name of the Business
Turnover this year
Profit this year
Turn over last year
Profit last year
How long have you been in the current bracket of revenue and profit?
How is your business currently?
What is the name of your company/organisation that you work for?
What is your Job Title?
How long have you been in this company/organisation?
How much are you earning right now per annum?
Are you going through a crisis (something that is taking a toll on your happiness, effectiveness, speed, peace of mind) in any of the following areas:
Relationships - Personal
Relationships - Professional
Mental Health
Physical health
Finance
No, I'm Not having a Crisis
Elaborate about the crisis that is taking a toll on your happiness, effectiveness, speed, peace of mind
5-10 years from now, Ideally, what would you like to do? What would you love to accomplish? Ideally.
Tell us more about your dreams and goals, your expectation from your own life.
If an Angel came by, and granted you 3 superpowers, what would you ask for?
What's your Legacy going to be? What would you like to be remembered as?
What Capabilities must you develop to Launch your Legacy?
Top 5 Personal Transformation would you like to make, for you to make a BIG Leap in your Life, Get Accelerated Success, and eventually Launch your Legacy, not in 10 years, but in 3 years or lesser?
On a scale of 1-10, how ready are you to undergo the Personal Transformation necessary, for your Accelerated Success?
10
9
8
7
6
5
4
3
2
1
(10 is the highest)
I hereby confirm the information I have provided above is true and accurate to the best of my knowledge.This question is required.
*
I Accept
I don't Accept
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